Forms

Medical Checkup

Child Health Clinical Record

These forms are available for providers to use as a documentation tool for all required checkup components. They should never be given out as a client questionnaire. The forms are recommended for your use by Texas Health Steps; they are not required.

Please note that forms have been updated to reflect July 1, 2018, Texas Health Steps policy changes for ages birth through 12 months and 12 to 18 years old. More details about these policy changes can be found on the Medical Providers page.

How to Download Child Health Record Forms

Go to the Texas Health Steps online catalog and click on the Browse button. Under Main Menu, click on View Catalog Items, then Child Health Records located on the left navigational pane. Select the record for the appropriate age, then click on the yellow starburst to download a printable and fillable PDF.

How to Use Child Health Clinical Record Forms

Please review these written instructions for using Child Health Record forms (PDF). The PDF forms include fillable fields (text fields, check boxes, etc.) so that you can complete the forms using Adobe Reader. Visit the File Viewing webpage for information on downloading Adobe Reader.

Developmental and Mental Health Screening

TB Questionnaire

Hearing Screening Questionnaire

Laboratory Tests

Referrals

ECI Referral Form

Texas Health Steps Provider Outreach Referral Form

The Texas Health Steps Provider Outreach Referral form should be used by all providers who submit a referral on behalf of a THSteps patient who needs assistance:

  • Scheduling a follow-up appointment.
  • Rescheduling a missed appointment.
  • Scheduling transportation to an appointment.
  • With other outreach services.

The following limitations and restrictions apply to the use of the THSteps Provider Outreach Referral form:

  • Only one referral form can be used for up to two patients in a household; if there are more than two patients in the same household, an additional referral form must be used.
  • Referrals should not be submitted for patients who are 21 years of age or older or are insured by the Children's Health Insurance Program.

The referral form is available in either Microsoft Word or Portable Document Format (PDF), and can be completed by hand or electronically and faxed using the coversheet included with the form. Download the instructions (PDF) for more information.

THSteps providers who have questions about the referral form, or need information about the THSteps Provider Outreach Referral Service, should contact the appropriate THSteps Provider Relations representative in their region (PDF).

Growth Charts

Additional Questionnaires, Forms, and Tools

Contact Texas Health Steps Regional Provider Relations Staff.

Download PDF

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